NSW Child Death Review Team Annual Report 2024-25
CDRT Annual Report 2024 25
PDF - 877KB
CDRT Annual Report 2024 25
PDF - 877KB
The NSW Child Death Review Team (CDRT) Annual Report 2024-25 describes the operations and activities of the CDRT during the period 1 July 2024 to 30 June 2025.
The CDRT is responsible for registering, classifying, analysing, and reporting to the NSW Parliament on data and trends relating to all deaths of children aged 0-17 years in NSW. Its purpose is to prevent or reduce the likelihood of deaths of children in NSW.
This annual report describes the operations of the NSW Child Death Review Team (CDRT) during the period 1 July 2024 to 30 June 2025.
The report has been prepared pursuant to section 34F of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (the Act). The Act requires the CDRT to prepare an annual report of its operations during the preceding financial year. The report must be provided to the Presiding Officer of each house of Parliament, and must include:
The report is arranged in the following chapters:
At the time of tabling, all CDRT information, publications and reports are available on the NSW Ombudsman website. The CDRT will be launching its own website in early November 2025, and following this, some CDRT documents will only be available on the CDRT’s website.
Since 1996, the NSW Child Death Review Team (CDRT) has been responsible for registering, classifying, analysing, and reporting to the NSW Parliament on data and trends relating to all deaths of children aged 0-17 years in NSW. The CDRT’s purpose is to prevent or reduce the likelihood of deaths of children in NSW through the exercise of its functions under Part 5A of the Community Services (Complaints, Reviews and Monitoring) Act 1993 (the Act).
CDRT membership is prescribed by the Act. Members are:
The Ombudsman, the Commissioner and the Advocate are ex officio appointments. Other members are appointed by the Minister administering the Act and may be appointed for a period of up to 3 years, with capacity for re-appointment.
The CDRT must have at least 17 and no more than 23 members. The CDRT must elect one member to be the Deputy Convenor, who may undertake some of the roles of the Convenor in his or her absence, including chairing of meetings.
All members of the CDRT, even if nominated because they are employed in a particular agency, are members as individuals and not as spokespeople for their agency.
Mr Paul Miller PSM (Convenor)
NSW Ombudsman
Mr Chris Clayton[1]
Senior Deputy Ombudsman, Systems Oversight & Reviews,
Community Services Commissioner
Ms Zoë Robinson
NSW Advocate for Children and Young People
Ms Sarah Bramwell
Director Practice Learning, Office of the Senior Practitioner
Department of Communities and Justice
Ms Vanessa Chan (on leave)
Director, Criminal Law Specialist, Policy and Reform Branch
Department of Communities and Justice
Dr Helen Goodwin
Chief Paediatrician/Senior Clinical Advisor Paediatrics
NSW Health
Senior Staff Specialist Paediatrician
Royal North Shore Hospital
Ms Anne Reddie
Director Child Wellbeing and Mental Health Services, Student Support
and Specialist Programs
Department of Education
Ms Alison Sweep
Director, Inclusive Practice
Department of Communities and Justice
Ms Amy Vincent-Pennisi (on leave)
Coronial Information Support Program Coordinator
NSW State Coroners Court
Representative of the NSW Police Force (vacant)[2]
Dr Susan Adams
Senior Staff Specialist, General Paediatric Surgeon
and Head of Vascular Birthmarks Service
Sydney Children’s Hospital
Associate Professor, School of Women’s and Children’s Health
University of New South Wales
Dr Susan Arbuckle
Paediatric/Perinatal pathologist
The Children’s Hospital at Westmead
Ms Jennifer Black
Commissioner
Mental Health Commission of NSW
Professor Ngiare Brown
Chancellor, James Cook University
Chair, National Mental Health Commission Advisory Board
Director and Program Manager, Ngaoara Child and Adolescent Wellbeing
Executive Manager Research and Senior Public Health Medical Officer, National Aboriginal Community Controlled Health Organisation
Professor of Indigenous Health and Education, University of Wollongong
Professor Kathleen Clapham AM (Deputy Convenor)[3]
Honorary Professor
Ngarruwan Ngadju First Peoples Health and Wellbeing Research Centre
School of Medical, Indigenous and Health Sciences
University of Wollongong
Dr Luciano Dalla-Pozza
Head of Department (Cancer Centre for Children)
Senior Staff Specialist (Paediatric Oncology)
The Children’s Hospital at Westmead
Dr Bronwyn Gould AM
General Practitioner
Professor Ilan Katz
Professor Social Policy Research Centre
University of New South Wales
Dr Matthew O’Meara
Senior Staff Specialist Paediatric Emergency Medicine
Sydney Children’s Hospital Randwick
Dr Lorraine du Toit-Prinsloo
Chief Forensic Pathologist and Clinical Director
Forensic Medicine Newcastle
Forensic and Analytical Science Services
NSW Health Pathology
Ms Monica Wolf (to 27 June 2025)
Chief Deputy Ombudsman, Community Services Commissioner
Detective Superintendent Danny Doherty (to 10 April 2025)
Commander Homicide Squad, State Crime Command
NSW Police Force
The Act provides for the Convenor to appoint persons with relevant qualifications and experience to advise the CDRT in the exercise of its functions. Expert advisers who assisted the CDRT in its work and/or who undertook research on behalf of the CDRT during 2024-25 include:
Under Part 5A of the Act, the CDRT’s functions[4] are to:
The CDRT reports directly to the NSW Parliament, with oversight by the Parliamentary Committee on the Ombudsman, the Law Enforcement Conduct Commission and the Crime Commission. There are three provisions in the Act under which the CDRT is required to report to Parliament:
All reports are available on the NSW Ombudsman website. From early November, all CDRT reporting will be available on the CDRT’s new website: www.cdrt.ombo.nsw.gov.au.
Members of the CDRT adhere to a Charter and Code of Conduct that outlines the CDRT’s scope, purpose and values, requirements of members, and other matters such as conflict of interest, confidentiality, and privacy.[5]
The Charter identifies the CDRT’s vision and purpose as well as detailing its specific legislative powers and authority, its values, strategic priorities, and operational imperatives.
The CDRT’s vision is:
"A society that values and protects the lives of all children, and in which preventable child deaths are eliminated."
The CDRT’s purpose is:
"To eliminate preventable child deaths in New South Wales by working collaboratively to drive systemic change based on evidence."
The CDRT’s vision and purpose are further expressed through its strategic priorities.
The CDRT’s 2022-2025 Strategic Priorities identified its main priorities for this three-year period and initiatives to achieve them. These priorities, and progress against the initiatives that sit underneath the priorities during the reporting year, are included at Appendix 1.
Highlights over the three-year Plan include:
To further the CDRT’s first strategic priority (nurturing strategic relationships and collaboration with key partners and stakeholders to optimise its influence and reach), the CDRT targeted 3 key stakeholders for engagement on the Biennial report of the deaths of children in New South Wales: 2020 and 2021. The CDRT prepared a fact sheet for the NSW State Coroner’s Office, and presented to Senior Coroners on the CDRT’s functions. The Coroner’s Office routinely requests information about individual child deaths to inform their inquests and there has been a significant increase in information requested and provided. The CDRT have also strengthened engagement with agencies to whom the CDRT has made recommendations, through holding meetings to discuss progress with agencies prior to issuing formal monitoring correspondence. This strengthened engagement has improved our reporting of issues and monitoring of recommendations, facilitated relationship building, and provided a forum for the sharing of information relevant to other areas of our work that the CDRT may not otherwise have access to.
Three strategic priorities included initiatives related to the CDRT’s research function, including improved data quality and sharing, collaboration with research and community partners and the alignment of CDRT research projects with its goals and objectives. A research framework to guide the prioritisation, delivery and communication of research projects was developed, as well as an internal procedure for responding to external requests for data from the Register of Child Deaths.
Initiatives under two strategic priorities sought to improve the CDRT’s public reporting in respect of the visibility of its work and data. A revised format was developed for CDRT biennial child death review reports that focused on the visual presentation of data and enhanced highlighting of key emerging issues. This revised format will be used in the Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament, to be tabled in November 2025.
Two strategic priorities sought to enhance the CDRT’s data and reporting through considering societal stressors (such as COVID-19) and inequitable child mortality outcomes. Societal stressor data is now collected in the Register of Child Deaths, and considered in the Research Framework. The Biennial report of the deaths of children in New South Wales: 2020 and 2021 introduced reporting on LGBTIQ+ children in the context of suicide, and the upcoming Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament will incorporate reporting on children with a child protection history as a distinct cohort.
To support the initiative to deliver powerful and influential evidence-based recommendations that bring about change, the CDRT completed a review of the impact of recommendations from 2017‑2022 to identify learnings for future recommendations. This review highlighted the critical importance of earlier and deeper engagement and consultation with agencies about CDRT recommendations, which has been incorporated into standard practice.
To support development of the new CDRT Strategic Priorities for 2025-2030, the NSW Ombudsman convened a planning day for CDRT members (25 February 2025) and presented the proposed priorities and enablers for discussion and endorsement (27 May 2025).
Strategic areas explored in those discussions include effective collaboration between the CDRT and NSW Ombudsman’s Office staff supporting the CDRT, ways that the CDRT can build relationships and influence the ecosystem it sits within, collecting and sharing data for the greater good, amplifying the impact of issues identified and recommendations made, and testing the currency of the CDRT’s legislative model and its fit with the future needs of society. These issues have been translated into five strategic priorities and two key enablers that will sit above initiatives to implement those priorities in the same way as the previous plan.
On 9 September 2025, the CDRT endorsed its Strategic Priorities 2025-2030 and initiatives to implement these priorities. This will be available on the new CDRT website in early November 2025.
The CDRT met formally on four occasions in 2024-25: September 2024, November 2024, February 2025, and May 2025. Two meetings were held in person and two via an online platform. An attendance table is at Appendix 2.
In December 2024, the NSW Ombudsman conducted an annual governance survey of CDRT members and expert advisers. The confidential survey sought feedback about their views and experiences of CDRT meetings, NSW Ombudsman secretariat support and the CDRT composition over the calendar year. The 2024 survey introduced questions about possible improvements, risks, threats and challenges. This was the third annual member survey. Responses across the period have been largely consistent.
Consolidated results of the survey were shared with the Convenor and with the CDRT in the February 2025 workshop. Survey results indicated that while secretariat support is a continuing strength, some members had a desire and capacity for increased involvement with CDRT projects.
Suggested improvements included seeking to raise the profile of the CDRT and the Register of Child Deaths, and growing collaboration with external entities through information exchange and project and research partnerships to achieve increased positive impact. These goals informed the development of the CDRT’s new strategic priorities for 2025‑2030 and are reflected across the priorities, in particular to promote awareness of the CDRT to extend its reach, and to enhance open and constructive relationships with key agencies.
The CDRT’s day-to-day work is supported by staff of the Child Death Reviews Unit in the NSW Ombudsman’s Office. The unit is also responsible for the Ombudsman’s reviewable child death function.[6] At the end of the 2024-25 period, this unit comprised 19 staff.
Work undertaken by staff to assist the CDRT includes:
Some CDRT members receive sitting fees in accordance with the NSW Government Boards and Committees Guidelines[7] and the Act.
The CDRT is required to table a report of data collected and analysed in relation to child deaths every two years.
The CDRT’s Child Deaths in NSW 2022 and 2023 Biennial Report to Parliament will be tabled in November 2025. Following tabling, the report will be accessible on the CDRT’s new website which will be launched on the same day.
Chapter 7 of this report includes detailed information from agencies about their actions to implement two recommendations currently being monitored by the CDRT. These two recommendations relate to Sudden Unexpected Death in Infancy (SUDI) prevention (1) and suicide prevention (1).
Research is an important way of examining causes and trends in child deaths, and to identify measures that can assist in preventing or reducing the likelihood of child deaths.
The Act anticipates that the CDRT will table a research report in Parliament on a triennial basis, with reasons required to be given if such a report has not been presented within the previous 3 years. Most recently, the CDRT published Infant deaths from severe perinatal brain injury in NSW, 2016-2019: key thematic observations on 27 November 2023.[8]
In September 2024, the CDRT published a framework to support its research functions. The framework guides the prioritisation, delivery and communication of research projects; ensures the CDRT’s approach to research is consistent, equitable and inclusive; supports collaboration with stakeholders; and aligns research projects with the latest CDRT Strategic Priorities and the NSW Ombudsman’s Strategic Plan. The Framework has been used to guide the CDRT’s current research (see Section 4.2), including establishing the governance arrangements for each project and considering the particular issues referred to in the appended Schedule for externally commissioned research in the appointment of external research organisations.
A copy of the Research Framework is available on the NSW Ombudsman’s website.
Aboriginal and Torres Strait Islander children and young people are over-represented in suicide deaths of children and young people aged 10-17 years. Over the ten-year period 2011-2020, the NSW Register of Child Deaths recorded the deaths by suicide of 238 children and young people aged 10-17 years, of whom 43 were identified as being of First Nations background.
The primary aim of the project is to identify opportunities for preventing and reducing the likelihood of suicide deaths of Aboriginal and Torres Strait Islander children. The CDRT has engaged the Ngarruwan Ngadju First People Health and Wellbeing Research Centre to conduct the research. Aboriginal members of the CDRT are acting as project sponsors overseeing the key findings and outcomes of this work.
The project includes:
The research report, Holding Hope: Preventing Suicide among Aboriginal and Torres Strait Islander Young people in New South Wales, will be tabled in NSW Parliament with an accompanying community report in November 2025.
The follow-up review of perinatal deaths from severe brain injury in 2020-2023 builds on the preliminary review of deaths in 2016-2019, which reviewed neonatal deaths associated with asphyxia-related causes such as hypoxic ischemic encephalopathy over the 4-year period. The preliminary review considered a range of factors such as infant characteristics; maternal characteristics; risk factors for fetal/newborn compromise; pregnancy, labour, and birth characteristics; maternal and newborn care; and pregnancy, pre- and post-death investigations. It found key thematic areas, with strong validity and consistency with the evidence-base, of fetal intrauterine growth restriction, decreased fetal movements, fetal heart rate monitoring, post-birth/newborn onset of deterioration, use of oxytocin to induce labour, instrumental vaginal birth and critical incident investigation.[9]
The objectives of this follow-up research are to understand the key contributory factors in infant deaths from severe perinatal brain injury in NSW; identify opportunities, and make recommendations, for the prevention of future deaths; and identify and assess the adequacy of clinical practice guidelines and policies, adherence to these guidelines and policies, and any changes made since the preliminary study.
In 2024-25, the follow-up review was approved by the CDRT, funding was allocated and a procurement process led to the selection of the University of Sydney as the research partner to undertake all elements of the research. The research is expected to be completed by late 2026.
The review of suicide-related deaths from 2018-2023 among young people aged 10-17 years who identified as LGBTIQ+ aims to:
The methodology includes a cohort review, a literature review of effective preventative measures, and a desktop review of countermeasures currently in place in NSW to support LGBTIQ+ young people.
In 2024-25, the project plan was approved by the CDRT, funding was allocated and a procurement process led to the selection of a research partner to undertake the literature and desktop reviews. The research is expected to be completed by mid-2026.
In addition to the CDRT’s review and research work it is also involved in other activities, including making submissions to Parliament and government, and engaging with similar functions across Australia to share knowledge and promote efforts to prevent future deaths of children.
The Australia and New Zealand Child Death Review and Prevention Group involves member representatives from every state and territory in Australia and New Zealand. The group meets every year to share information, knowledge, and ideas about child death-related work to assist members to meet their common goal of preventing deaths of children. The role of convening the group rotates among jurisdictions, and is currently held by the Queensland Family and Child Commission (QFCC).
The group’s fifth ‘virtual’ annual conference was held on 20 May 2025. The conference offers a professional development opportunity for people working in child death prevention, registration, review, policy and research. Presentations included:
The CDRT sent 4 submissions (or other correspondence providing information from CDRT reports and the Register of Child Deaths) to various inquiries and NSW Government Ministers over the year:
Section 34L(1)(a) of the Act allows the disclosure of information in good faith for the purpose of exercising a function under Part 5A of the Act. Under this provision, the CDRT provided the following information:
The CDRT is required to include in this annual report whether any information has been disclosed by the Convenor under section 34L(1)(b) of the Act. The section allows the Convenor to authorise the release of information acquired by the CDRT in connection with research ‘that is undertaken for the purpose of helping to prevent or reduce the likelihood of deaths of children in NSW.’ Under this provision, the following information was provided:
Section 34L(1)(c) of the Act allows the disclosure of information to certain entities for specified purposes, in relation to deaths within their jurisdiction. Under this provision, the CDRT provided the following information:
Section 34L(1)(c)(vi) provides for disclosure for the purpose of ‘giving effect to any agreement or other arrangement entered into under section 34D(3)’. Section 34D(3) allows the Convenor to enter into an agreement or other arrangement for the exchange of information between the CDRT and a person or body having functions under the law of another State or Territory that are substantially like the functions of the CDRT.
The CDRT currently has formal agreements in place with similar bodies in the Australian Capital Territory and Western Australia and provides information to bodies in other States and Territories on a case‑by‑case basis. The CDRT also put in place a one-off data sharing agreement with AIHW in March 2025 to support the exchange of data for the purpose of the national child death data collection project.
In this context, information was provided to the following agencies between 1 July 2024 and 30 June 2025 in response to requests received:
The CDRT can make recommendations aimed at preventing or reducing the likelihood of child deaths.
Recommendations can be for new or amended legislation, policies, practices, and services. They can be directed to government and non-government agencies, or to the community.
Under sections 34F(2)(b) and (3) of the Act, the CDRT annual report:
must include details of the extent to which its previous recommendations have been accepted, and
may comment on the extent to which those recommendations have been implemented in practice.
The CDRT recognises that in some cases it can take time for agencies to implement recommendations fully, and some recommended changes may be made incrementally.
Accordingly, as well as reporting on any new recommendations made during the reporting year, the CDRT also looks at any open recommendation from previous years, and decides and reports on whether:
At the beginning of this reporting period there were two open CDRT recommendations. These relate to SUDI prevention and suicide prevention. These recommendations are detailed below, along with a report on the status of each recommendation.
Recommendation | Date of recommend-ation | Agency responsible | Agency | CDRT monitoring of implementation (2025) |
|---|---|---|---|---|
SUDI – Policy Directive review NSW Health should review PD2019_035 Management of Sudden Unexpected Death in Infancy, having regard to the results of its audit of compliance with the revised SUDI medical history protocol completed in October 2023. As part of this review, NSW Health should consult with relevant stakeholders referred to in the Policy and the CDRT. | October 2024 | NSW Health | Supported | To be closed - implemented |
Suicide – targeted prevention measures The NSW Government should include in any suicide prevention plan specific measures targeted to school-aged children and young people across the spectrum of need. In particular, this should include: a. (element met and closed in 2021-22) b. (element met and closed in 2022-23) c. The provision of targeted, sustained, and intensive therapeutic support to young people at high risk – including strategies for reaching those who are hard to engage. | June 2019 | NSW Health | Supported | Continue monitoring |
Recommendation 1, NSW Child Death Review Team Annual Report 2023-24 (published October 2024)
NSW Health should review PD2019_035 Management of Sudden Unexpected Death in Infancy, having regard to the results of its audit of compliance with the revised SUDI medical history protocol completed in October 2023. As part of this review, NSW Health should consult with relevant stakeholders referred to in the Policy and the CDRT.
Following the introduction in 2019 of a revised guide for taking an infant’s medical history after a SUDI death (the Medical History Guide – Sudden Unexpected Death in Infancy, part of the NSW Health Policy Directive PD2019_035 Management of Sudden Unexpected Death in Infancy (SUDI)), the CDRT made a recommendation to NSW Health in 2021 to audit use of the updated Guide.
In October 2023, NSW Health advised that it had completed the audit, and provided formal advice on the audit findings and outcomes to the CDRT. The audit found that compliance with the Medical History Guide was below expectations. The SUDI cross-agency working group[10] considered the audit findings and agreed to review the Policy Directive.
Given the review of the Policy Directive had not yet commenced, and to ensure relevant stakeholders were consulted, the CDRT made the above recommendation in October 2024. NSW Health advised its acceptance of the new recommendation in December 2024.
NSW Health advised that the review of the Policy Directive consisted of a desktop review and the development and finalisation of a draft SUDI response model and draft SUDI policy. Throughout the review process, NSW Health consulted with Ministry of Health and agency advisers (Prevention and Response to Violence, Abuse and Neglect, Senior Clinical Advisor workforce, Chief Paediatrician, Senior Clinical Advisor Child and Family Health, Centre for Aboriginal Health, Health Chief Executives), agency representatives (NSW Ambulance, NSW Health Pathology Forensic Medicine, Red Nose, NSW Police, NSW Department of Communities and Justice, Office of the NSW State Coroner), and clinicians (Local Health District/clinician representatives, paediatricians/paediatric clinical nursing consultants, emergency physicians, rural GPs and visiting medical officers, social workers). NSW Health advised that they took a holistic approach to the review, incorporating consideration of how agencies interact, how services wrap around families, and any revisions required in light of international research in addition to the audit findings.
The audit findings indicated that while paediatricians usually completed the medical history interviews, they recorded the interviews differently. Some staff used the 2019 Medical History Guide, while others used a previous template or recorded additional information in other ways. In some cases, an interview or record was not provided to Forensic Medicine as required and when the information was provided, the level of detail varied. P79A forms (Report of Death to Coroner) were found to be important sources of information. Reasons why a medical history was not completed were generally not documented, but those that were cited high levels of family distress, or that the interview had already been or would be conducted by Police.
NSW Health met with NSW Ombudsman staff in November 2024 and March 2025, and then the CDRT in May 2025, with the CDRT providing both oral and written feedback on the revised Policy Directive.
NSW Health advised in August 2025 that consultation on the draft revised policy review had been completed and the Policy Directive review is expected to be completed by early 2026. All stakeholders will be advised of the revised Policy’s publication.
NSW Health’s review of PD2019_035 Management of Sudden Unexpected Death in Infancy has considered the results of its audit of compliance with the revised SUDI medical history protocol completed in October 2023 and has involved consultation with relevant stakeholders referred to in the Policy, including the CDRT. Therefore, the recommendation will be closed as met.
Recommendation 10, Biennial report of the deaths of children in NSW: 2016 and 2017 (published June 2019)
The NSW Government should include in any suicide prevention plan specific measures targeted to school-aged children and young people across the spectrum of need. In particular, this should include:
At the time the recommendation was made, the suicide rate for young people aged 10-17 years had increased over the prior decade, and the CDRT observed school-age young people to have particular vulnerabilities and needs that should be considered in suicide prevention strategies. It observed that NSW generally had good systems for identifying young people who are at risk of suicide or who are dealing with mental health problems, but that intervention – once a problem is identified – could be episodic and fragmented. Identification of suicide risk must be supported by effective strategies to manage and contain risk to prevent suicide.
The CDRT also observed that, in NSW, demand for access to developmentally appropriate specialist mental health services for children and young people regularly outstripped the capacity to supply timely services. The Strategic Framework for Suicide Prevention in NSW 2018-2023 (the Framework)[11]
supported whole of government suicide prevention activity across all NSW communities and was identified as a foundation for targeted youth mental health services.
The NSW Government supported the recommendation, and delegated responsibility for providing its updates to NSW Health.
Between 2021 and 2023 NSW Health provided information on a range of Child and Adolescent Mental Health Services (CAMHS), Towards Zero Suicides and National Mental Health and Suicide Prevention Agreement suicide prevention initiatives, including the Getting on Track in Time – Got it! programs, Safeguards Teams, the Youth Aftercare Pilot (YAP) program (branded “i.am”), Zero Suicides in Care, Suicide Prevention Outreach Teams (SPOT), Safe Havens, Project Air Schools initiative, Head to Health Kids Hubs, the Enhancement and Integration of Youth Mental Health Services Initiative, Youth Community Living Support Services, and an out of home care (OOHC) mental health framework being developed in partnership with DCJ.
In June 2024, in the context of reported shortages of beds and psychiatrists and increasing presentations, NSW Health provided advice about initiatives including a gap analysis on community mental health services conducted by the NSW Mental Health Minister in December 2023,[12] and a revised psychiatry workforce plan. They highlighted the role of Safeguards Teams in assessing and linking young at-risk patients with appropriate longer term care services provided by CAMHS, private practice clinicians, psychosocial support services, and housing and education services.
In May 2025 representatives from the NSW Ombudsman met with NSW Health staff to discuss the recommendation. NSW Health provided updates on the community mental health services gap analysis, evaluation of the Safeguards Teams and their flexible service delivery models, and Kids Hubs (formerly Head to Health Kids Hubs). NSW Health also advised about its management of the impact of the industrial action involving NSW public health psychiatrists.
In August 2025 NSW Health advised that following the gap analysis paper, a report of the findings of service mapping using service planning and simulation (modelling) tools will be made available in 2025-26. They noted that they are modelling demand for CAMHS, adult and older adult services, both inpatient and community ambulatory, and that Local Health Districts will be consulted about the findings to provide further context.
NSW Health advised that the joint framework with DCJ to guide the provision of mental health care for children in OOHC, the Mind My Wellbeing framework, would soon be published.
NSW Health provided interim evaluations of the Safeguards Teams, conducted in 2023 and 2024, that found the Teams fill an important gap in responding to children in mental health crisis. The 2024 evaluation found consumers had fewer mental-health related ED presentations and hospital readmissions, and improved clinical outcomes, following contact with Safeguards. It made 11 recommendations for improvement of the program, including in relation to the extension of care beyond 6 weeks, and workforce and culture.
The evaluation’s findings support the CDRT’s observations regarding the importance of accessible long-term mental health services, and the workforce challenges currently experienced by the sector. Notably, the Safeguards model of care recommends a 6-week period of care in the program. While the average length of care was 4 weeks and 4 days, the evaluation observed that 1 in 10 consumers engaged with Safeguards for 12 weeks or more. This was due to the time needed to build trust and rapport, as well as holding consumers during a transition period or gap in service support. Consumers reported that the transition from Safeguards to longer-term care was sometimes fragmented, leading to these gaps in support. Identified challenges for the program included workforce recruitment and limited long-term service availability, due to demand outpacing supply.
NSW Health advised that CAMHS teams were provided with support in managing the impacts of the industrial action involving NSW public health psychiatrists. They advised that there were no temporary service reductions within CAMHS, and the Ministry monitors all reportable incidents.
NSW Health noted that the Suicide Prevention Bill 2025[13] would establish a whole-of-government approach to suicide prevention with cross-portfolio delivery of suicide prevention programs. The Bill proposes a Suicide Prevention Council and Aboriginal Suicide Prevention Council to advise the Mental Health Commission in the preparation of a statewide suicide prevention plan and statewide Aboriginal suicide prevention plan, both to be reviewed at least every 5 years. The Councils can also provide advice to the Mental Health Commission about improvements to suicide prevention, and the Aboriginal Suicide Prevention Council can make recommendations to the Mental Health Commission regarding the Aboriginal suicide prevention plan. The statewide suicide prevention plans are to have regard to the needs of priority population groups among other considerations. Departments, the NSW Police Force and other prescribed agencies will also be required to have agency suicide plans.
The Mental Health Commission can report on the implementation of suicide plans, and must annually report on advice or recommendations received from the Councils, and whether that advice or those recommendations were accepted and implemented. The Secretary[14] may keep a register of suicide deaths with the purpose of monitoring and reporting on suicide deaths, identifying risk factors or patterns, and enabling the identification and monitoring of suicide prevention and response strategies.
NSW Health also provided advice on funding to 6 men’s mental health organisations providing wellbeing and support services to young men (aged 10-25 years), suicide bereavement support for children and young people, and the NSW Suicide Monitoring System.
The CDRT acknowledges NSW Health’s continued endeavours to enhance child and adolescent mental health services and that its programs and initiatives provide a foundation for targeted, sustained and intensive therapeutic support to young people at high risk of suicide. The CDRT notes the findings of the Industrial Relations Commission (IRC) on 3 October that “(t)here is an acute shortage of psychiatry staff specialists, distinguishable from other staff specialists, which is causing a deterioration in the quality of mental health care delivered in the public health system in New South Wales and a deterioration in the working conditions of psychiatrists.“[15]
The CDRT notes the shortfalls in the provision of targeted, sustained and intensive therapeutic support, partially due to ongoing challenges in recruiting and maintaining an adequate workforce. The CDRT acknowledges that some of these challenges require long-term, systemic change, and there are efforts to map some of these required changes in the service modelling underway. In relation to the impact on children and young people at risk of suicide as a priority group, the CDRT will monitor the implementation of the NSW Suicide Prevention Act, and the Mind My Wellbeing framework for children in OOHC. Therefore, the CDRT will continue to monitor this recommendation.
The CDRT made one recommendation during the 2024-25 reporting year, see section 7.2.
Please see page 26-32 of the report.
[1] Mr Chris Clayton was appointed as Community Services Commissioner effective 30 June 2025. Ms Monica Wolf was formerly the Chief Deputy Ombudsman and Community Services Commissioner in the period 1 July 2024 to 27 June 2025.
[2] Detective Superintendent Joseph Doueihi, Commander Homicide Squad, State Crime Command, NSW Police Force was appointed as the NSW Police representative on 1 July 2025. Prior to his appointment, Mr Doueihi was appointed as an expert adviser.
[3] Professor Clapham has stepped aside from the position of Deputy Convenor until the conclusion of the Review of the suicide deaths of Aboriginal children and young people.
[4] Under Part 6 of the Act, the NSW Ombudsman also has a separate function to review the deaths of children in circumstances of (or suspicious of) abuse and neglect, and the deaths of children in care or detention (known as ‘reviewable’ child deaths). Further information about the Ombudsman’s reviewable deaths function is available on the NSW Ombudsman website and in the NSW Ombudsman’s Annual Reports.
[5] These documents can be accessed at: https://www.ombo.nsw.gov.au/about-us/what-we-do/our-statutory-functions/child-death-review-team-cdrt.
[6] See note 4 above.
[7] NSW Government, NSW Government Boards and Committees Guidelines, September 2015
[8] This research report was tabled together as an annexure with the Biennial report of the deaths of children in New South Wales: 2020 and 2021. See NSW Ombudsman, Annexure B to the Biennial report of the deaths of children in New South Wales: 2020 and 2021, 27 November 2023, p. 219.
[9] See note 8 above.
[10] The SUDI Cross Agency Working Group (CAWG) was established in response to a previous CDRT recommendation, Recommendation 3 in the Child Death Review Report 2015 (published November 2016). NSW Health has had responsibility for the management of the CAWG since July 2019; NSW Child Death Review Team Annual Report 2020-21 p 17.
[11] Since replaced by the Strategic Framework for Suicide Prevention in NSW 2022-2027.
[12] NSW Ministry of Health (2023) NSW Community Mental Health Services Priority Issues Paper, published December 2023.
[13] The Suicide Prevention Bill 2025 passed New South Wales Parliament on 11 September 2025. A commencement date for the Act has not yet been proclaimed.
[14] The Bill provides that this refers to the Secretary of the Department in which the Act will be administered on behalf of the Minister.
[15] Health Secretary, Ministry of Health v Australian Salaried Medical Officers’ Federation (New South Wales) (No 2) [2025] NSWIRComm 27
We acknowledge the traditional custodians of the land on which we work and pay our respects to all Elders past and present, and to the children of today who are the Elders of the future.
Artist: Jasmine Sarin, a proud Kamilaroi and Jerrinja woman.